Take a Breath

“You assume the risk of grief support, training and activities pursuant to Pennsylvania Law.”

The program at Hands Holding Hearts provides education, support, and therapy for children, teens, and adults who have experienced the loss of a significant person in their lives. All staff and volunteers working with clients have had personal and/or professional experience and training with loss and grief.

No participant will be accepted for bereavement services, and no volunteer accepted for service, until this form has been READ, UNDERSTOOD, COMPLETED AND SIGNED by the parent(s) or guardian(s) of a minor, or, if the participant or volunteer is of legal age and sound mind, by the participant or volunteer.

Although participation in the program is under strict supervision and every effort is made to avoid injury or accident, the undersigned acknowledges the inherent risks involved in engaging in grief counseling, workshops, and programs. This includes bodily injury from nature walks and craft projects, and emotional distress that may arise from discussing the loss.

I acknowledge the risks and potential for injury that may occur with the activities of grief counseling, programs, and workshops, and I have discussed these risks with my child and/or his/her/my physician. However, I feel that the possible benefits to myself/son/daughter/ward are greater than the risk assumed. I therefore agree to be legally bound, for myself (or for my son/daughter/ward), heirs, executors or administrators, and do hereby agree to release, hold harmless and indemnify Hands Holding Hearts, its Board of Directors, Therapists, Volunteers, Employees and the Township of Newtown, its Employees, Supervisors and Associates, harmless of any claim for loss, injury or damages of every kind and nature whatsoever while at Hands Holding Hearts located at 118 N. State St., Newtown, PA 18940, or while off the property in conjunction with a Hands Holding Hearts program.

Hands Holding Hearts shall preserve and respect the right of confidentiality for all individuals in our Bereavement Program. The board members, volunteers and staff of Hands Holding Hearts must keep confidential any and all medical, social, referral, personal, and financial information regarding individuals and their families in our program. The Executive Director of the program will address any breach of confidentiality. I understand and agree to abide by the confidentiality policy of Hands Holding Hearts.